Retail and Urgent Care Articles
Neither morphine+ibuprofen nor either drug alone+placebo improved pain to a minimal score at 1 hour in children with acute extremity pain.
A dose of ibuprofen 400mg + acetaminophen 1000mg was as good as an oral opiate for extremity pain.
This article is a sobering reminder that mistakes with online activity can cost one's career. We know the obvious blunders, but this editorial explores 3 more subtle ways our smartphones could damage our reputations.
Codeine prescriptions for children after tonsillectomy and adenoidectomy substantially dropped after the FDA issued a black box warning over safety concerns. Still, 1 in 20 children continue to inappropriately receive codeine after T&A.
It was a big job for ALiEM to come up with the list of 52 landmark articles you need to know as an Emergency Physician. But it's an even bigger job to sit down and read them. In fact, most of us just won't be able to find the time to do it. Because they are so important to know, I wanted to make it easier to get the gist of these articles. So each Saturday in 2017, I briefly summarized one of these key articles. For your convenience, here are the links and excerpts for each of the 52 in 52 article summaries in one place. Enjoy. And please share this with a friend. Special thanks to Dr. Michelle Lin for allowing me to partner with ALiEM and use the combined logos.
It was a great refresher to go back over the articles we covered in 2017. There were so many groundbreaking and practice changing articles. We have hand-picked some of our favorites.
Several myths surround the diagnosis of ectopic pregnancy. This review debunks them.
Children with isolated, non-depressed skull fracture did extremely well. Of 6646 children in this systematic review, none died and only one progressed to need neurosurgical intervention.
Naproxen + placebo was as good as (possibly better than) naproxen plus orphenadrine or naproxen plus methocarbamol for acute low back pain.
There is no such thing as a "black cloud." Those who self-identified as a black-cloud were also identified as such by their peers, but a look at the actual PED metrics showed no statistical difference except higher admission rate. I'm not sure I believe this, but there you go...
The Canadian CT Head Rule was 100% sensitive for ruling out clinically important brain injury. It had higher specificity than the New Orleans Criteria, which meant fewer people would need a CT scan by using the Canadian rule.
Bruising in premobile children means trouble. The most important take home is: "More than half of premobile infants with initially unexplained bruises were found to be abused." Bruising before they're cruising needs a workup and DCS referral.
Consider testicular torsion a surgical emergency even if it is past the usual 6-8 hour mark, which is traditionally taught as the outer limit of testicular viability. This study found that the testicle could still be salvaged over half the time from 13-24 hours from onset.
Sonographically occult perineal abscess in children was surprisingly common, 28% (61/217). More than half had I&D within 4 hours of a "negative" radiology-obtained ultrasound. Symptoms < 4 days, age < 4 years, and history of MRSA were all associated with false negative ultrasound.
The primary outcome (quick and sustained headache relief) was achieved in 60% of the IV prochlorperazine + diphenhydramine group vs 31% in the IV hydromorphone group with a NNT of 4. As a result, the study was stopped early.
Female surgeons had small but significantly improved 30-day mortality and other surgical outcomes over male surgeons, all other factors being equal.
We can't draw firm conclusions from this paper, since it was not designed or powered to detect differences in subgroups with skin abscesses. But it was notable that patients who received TMP/SMX did better than those who received placebo across all subgroups, including those with larger abscesses; especially those with fever, history of MRSA, or MRSA positive culture.
Applying an ice cube (inside a sterile glove) to the skin over a laceration for 2 minutes significantly reduced pain from local anesthetic injection.
In patients age 5 years through adulthood with sore throat of any cause, use of a single, low-dose steroid (most often dexamethasone 10mg or 0.6mg/kg for children, max 10mg; most given orally) were twice as likely to have pain relief at 24 hours.
Substantial agreement on clinical exam findings in children with suspicion of pneumonia was only present for wheezing and retractions. All other clinical exam findings had poor to moderate agreement between clinician examiners.
Diagnostic accuracy of the digitally interpreted rapid influenza A and B antigen tests (DIA) was better than the traditional rapid flu tests, 77-80% sensitive vs. 53-54% sensitive. In children compared to adults, the sensitivity was 18.5 points higher for flu A and 32 points higher for flu B with the traditional rapid test; 12 and 25 points higher for the DIA respectively; 2.7% points higher for nucleic acid amplification tests (NAATs). NAATs were about 95% sensitive overall. All tests had specificity of about 98%.
There was no difference in cosmetic outcome with use of absorbable vs. nonabsorbable suture for pediatric lacerations, though there was a nonsignificant trend to absorbable being superior. There was also no difference in dehiscence or infection rate between the two.
Why do people seek emergency or urgent care? This quick systematic review of the literature identified 5 reasons.
The diagnostic accuracy of rapid streptococcal antigen testing is such that a negative test rules out disease and should not be treated; a positive test rules it in and should be treated.
Medication overuse headache (MOH), also known as rebound headache or drug-induced headache, may be the stuff of legend. The evidence for it is sketchy. The authors say, "Until the evidence is better, we should avoid dogmatism about the use of symptomatic medication."
Fluoroquinolone antibiotics were associated with idiopathic intracranial hypertension.
Patients in an ED setting with a low pretest probability based on the Wells score, and a negative D-dimer were safely ruled out for pulmonary embolism without further diagnostic imaging.
No clinical criteria were powerful diagnostic discriminators of the presence or absence of pneumonia in children, though some were fair. When in doubt, a CXR is probably warranted, with the exceptions of obvious bronchiolitis or asthma. Low SpO2 (</= 95 to 96%) or increased work of breathing were the best predictors of radiographic pneumonia in children; auscultatory findings and tachypnea were poor. You don't need a CXR if no cough, no fever, no tachypnea, and normal SpO2.
Oral steroids were of no benefit for non-asthmatic patients with bronchitis.